Healthcare Provider Details

I. General information

NPI: 1043852601
Provider Name (Legal Business Name): SOUTHEASTERN CENTER FOR FERTILITY AND REPRODUCTIVE SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11126 KINGSTON PIKE
KNOXVILLE TN
37934-2806
US

IV. Provider business mailing address

PO BOX 25686
BELFAST ME
04915-2007
US

V. Phone/Fax

Practice location:
  • Phone: 865-777-0088
  • Fax: 865-777-2015
Mailing address:
  • Phone: 617-402-1000
  • Fax: 617-402-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN D. GORDON
Title or Position: OWNER
Credential: MD
Phone: 865-777-0088